Your client has anaphylaxis listed as a penicillin allergy. Which antibiotic would be safe for your client to receive?

Determining whether chest pain has been relieved. This is because nitroglycerin is a medication that is used to treat chest pain caused by cardiac origin or acute pulmonary edema. The main action of nitroglycerin is to relax and dilate the blood vessels, which reduces the workload of the heart and improves blood flow to the heart muscle.

Therefore, the most important nursing action after administering nitroglycerin sublingually is to assess if the chest pain has subsided or not.

Choice A is wrong because monitoring the client’s respiratory rate and effort is not the most important action after giving nitroglycerin. Although nitroglycerin can cause hypotension and bradycardia, which may affect the respiratory status, these are side effects that can be managed and are not life-threatening as chest pain.

Choice B is wrong because warning the client to lie still to prevent a headache is not a priority after giving nitroglycerin. Nitroglycerin can cause headache as a side effect, but this can be treated with analgesics and does not require the client to lie still. Moreover, lying still may increase the risk of venous thromboembolism in a client with peripheral vascular disease.

Choice D is wrong because verifying that the sublingual tablet produced a tingling sensation is not essential after giving nitroglycerin.

Although some sublingual tablets may produce a tingling sensation, this is not a reliable indicator of the drug’s effectiveness

Maintain trust and avoid behaviors that may increase agitation. This is the priority action because it is important for the nurse to attempt to de-escalate the client and maintain trust.

A. Ordering the client to go to their room and alerting security is not the priority action because it may increase agitation and does not maintain trust.

C. Telling the client to sit down or risk isolation and loss of privileges is not the priority action because it may increase agitation and does not maintain trust.

D. Sedating the client after collecting a lithium level is not the priority action because it does not address the immediate need to de-escalate the situation and maintain trust.